1033162425 NPI number — TRAVIS HALDEMAN D.O.

Table of content: TRAVIS HALDEMAN D.O. (NPI 1033162425)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033162425 NPI number — TRAVIS HALDEMAN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALDEMAN
Provider First Name:
TRAVIS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033162425
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 S LAKE PARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOBART
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46342-6638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-947-6153
Provider Business Mailing Address Fax Number:
219-703-6501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3545 ARBOR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46368-4298
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-636-9205
Provider Business Practice Location Address Fax Number:
708-229-6075
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  02004689A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 201321810 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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